Cesarean DeliveryCesarean Delivery

Cesarean section means delivery of a viable Cesarean section means delivery of a viable fetus through an abdominal incision (i.e., fetus through an abdominal incision (i.e., laparotomy) and a uterine incision (i.e., laparotomy) and a uterine incision (i.e.,

hysterotomy). The terms cesarean and section hysterotomy). The terms cesarean and section used together are actually redun dant, because used together are actually redun dant, because

both words imply incision. both words imply incision.

Labor ContraindicatedLabor ContraindicatedUnder certain conditions, forceful uterine contrac Under certain conditions, forceful uterine contrac

tions, as in normal labor, constitute a real or tions, as in normal labor, constitute a real or

potential hazard to mother or fetus, or bothpotential hazard to mother or fetus, or both.. Conditions in which the forces of labor increase Conditions in which the forces of labor increase

the risk to the mother include central placenta the risk to the mother include central placenta previa, previous classic cesarean section, previa, previous classic cesarean section, previous myomectomy tran secting the uterine previous myomectomy tran secting the uterine wall, previous uterine reconstruc tion, and wall, previous uterine reconstruc tion, and previous repair of a vaginal fistula. In such previous repair of a vaginal fistula. In such circumstances, normal labor and vaginal delivery circumstances, normal labor and vaginal delivery may result in uterine rupture, hemorrhage, or may result in uterine rupture, hemorrhage, or serious lacerations of the birth canal, and may serious lacerations of the birth canal, and may endanger the life or future health of the mother.endanger the life or future health of the mother.

Conditions that have traditionally been cited as threatening Conditions that have traditionally been cited as threatening the fetus and that may be worsened bythe fetus and that may be worsened by

labor include placenta previa, velamentous insertion of the labor include placenta previa, velamentous insertion of the

cord or other forms of vasa previa, and cord presentation.cord or other forms of vasa previa, and cord presentation. The majority of cesareans are performed for fetal The majority of cesareans are performed for fetal

indications; a few are solely for maternal reasons, indications; a few are solely for maternal reasons, and some benefit both fetus and mother. Repeat and some benefit both fetus and mother. Repeat cesarean accounts for approximately 33% of cesarean accounts for approximately 33% of cesarean births in the United States, dystocia is cesarean births in the United States, dystocia is the indication for up to 30%, and fetal distress, the indication for up to 30%, and fetal distress, breech, and all other conditions are responsible breech, and all other conditions are responsible for the remaining cases. Unfortunately, there are for the remaining cases. Unfortunately, there are few data to suggest that the liberalized in few data to suggest that the liberalized in dications for cesarean section have reduced the dications for cesarean section have reduced the in cidence of cerebral palsy and other long-term in cidence of cerebral palsy and other long-term disabilitiesdisabilities

This is probably because most perinatal morbidity and This is probably because most perinatal morbidity and mortality are caused by premature births, fetal anomalies, mortality are caused by premature births, fetal anomalies,

or antepartum events.or antepartum events.Failed InductionFailed Induction

In conditions such as isoimmunization, In conditions such as isoimmunization, diabetes mel-litus, intrauterine growth diabetes mel-litus, intrauterine growth retardation, and hyperten sive disorders, retardation, and hyperten sive disorders, which constitute an ever-increasing threat which constitute an ever-increasing threat to the fetus, preterm delivery may be to the fetus, preterm delivery may be desirable. If attempts to induce labor are desirable. If attempts to induce labor are inappropriate or un successful, cesarean inappropriate or un successful, cesarean section is the alternativesection is the alternative

Common Indications for Common Indications for Cesarean DeliveryCesarean Delivery

Failed inductionFailed induction Cephalopelvic disproportionCephalopelvic disproportion Failure to progress in laborFailure to progress in labor Proven fetal distressProven fetal distress Placental abruptionPlacental abruption Placenta previaPlacenta previa Umbilical cord prolapseUmbilical cord prolapse Obstructive benign and malignant tumorsObstructive benign and malignant tumors Active genital herpes infectionActive genital herpes infection Abdominal cerclageAbdominal cerclage Conjoined twinsConjoined twins Controversial (or Selective)Controversial (or Selective) Breech presentationBreech presentation Repeat cesareanRepeat cesarean Immune thrombocytopeniaImmune thrombocytopenia Severe Rh immunizationSevere Rh immunization Congenital fetal anomalies, majorCongenital fetal anomalies, major Cervical carcinomaCervical carcinoma Prior vaginal colporrhaphyPrior vaginal colporrhaphy Large vulvar condylomataLarge vulvar condylomata

For example, fetal macrosomia occasionally causes CPD, For example, fetal macrosomia occasionally causes CPD, but most cesarean births for abnormal labor involve a but most cesarean births for abnormal labor involve a

normal-sized infant. Dystocia also occurs because of soft tis normal-sized infant. Dystocia also occurs because of soft tis

sue tumors and abnormal fetal presentationssue tumors and abnormal fetal presentations Fetal DistressFetal Distress Electronic fetal monitoring probably increases the Electronic fetal monitoring probably increases the

chances of detecting fetal distress and has chances of detecting fetal distress and has contributed to the increased number of cesarean contributed to the increased number of cesarean sections in the United States. Vaginal breech sections in the United States. Vaginal breech deliveries have been abandoned by many deliveries have been abandoned by many clinicians and replaced by cesarean delivery. In clinicians and replaced by cesarean delivery. In this situation, cesarean birth avoids the potential this situation, cesarean birth avoids the potential risk of intrapartum asphyxia or delivery-related risk of intrapartum asphyxia or delivery-related trauma from head entrapment and umbilical cord trauma from head entrapment and umbilical cord prolapseprolapse

Classic incision in the upper Classic incision in the upper segment of the uterus.segment of the uterus.

Incisions in lower uterine segment. Incisions in lower uterine segment. (A) Low transverse incision. (B) (A) Low transverse incision. (B)

Low vertical incision.Low vertical incision.

On the other hand, reckless surgical techniques for rapid On the other hand, reckless surgical techniques for rapid delivery of the fetus should be condemned. An induction-to-delivery of the fetus should be condemned. An induction-to-

delivery time of 5 to 15 minutes is reasonable if maternal delivery time of 5 to 15 minutes is reasonable if maternal oxygen-ation, blood pressure, and displacement of the uterus oxygen-ation, blood pressure, and displacement of the uterus

are monitored and maintained with careare monitored and maintained with care.. Preparation of the abdomen includes Preparation of the abdomen includes

shaving the skin of the abdomen and shaving the skin of the abdomen and mons pubis when necessary, scrubbing the mons pubis when necessary, scrubbing the area with an antiseptic soap, and pre area with an antiseptic soap, and pre paring the skin with an antiseptic agent paring the skin with an antiseptic agent such as non-organic iodide. The abdomen such as non-organic iodide. The abdomen is draped so that the area between the is draped so that the area between the umbilicus and the mons pubis is exposed.umbilicus and the mons pubis is exposed.

The lower flap of peritoneum is elevated and the bladder is The lower flap of peritoneum is elevated and the bladder is gently separated by blunt or sharp dissection from the gently separated by blunt or sharp dissection from the

underlying myometriumunderlying myometrium

The visceral peritoneum is grasped just above the The visceral peritoneum is grasped just above the bladder and incised in the midline.bladder and incised in the midline.

A. The incision in a well-developed (thin) lower uterine A. The incision in a well-developed (thin) lower uterine segment is extended laterally and cephalad with the segment is extended laterally and cephalad with the

fingers. B. The incision in a thicker lower uterine segment is fingers. B. The incision in a thicker lower uterine segment is extended laterally with bandage scissors.extended laterally with bandage scissors.

The fetal occiput is lifted toward the incision. Care The fetal occiput is lifted toward the incision. Care is taken not to use the lower uterine segment as a is taken not to use the lower uterine segment as a

fulcrum in order to avoid lacerations.fulcrum in order to avoid lacerations.

The body is delivered after the mouth and nares The body is delivered after the mouth and nares

have been suctioned thoroughlyhave been suctioned thoroughly..

The placenta is delivered by shearing it manually The placenta is delivered by shearing it manually

from its uterine attachment.from its uterine attachment.

The second layer of closure imbricates the first; ab sorbable The second layer of closure imbricates the first; ab sorbable suture is used in interrupted stitches in figures-of-eight, in suture is used in interrupted stitches in figures-of-eight, in

Lembert stitches, or in a contin uous suture placed such that Lembert stitches, or in a contin uous suture placed such that

the first layer of closure is completely coveredthe first layer of closure is completely covered.. If, during the closure, any areas of If, during the closure, any areas of

bleeding are still apparent in the bleeding are still apparent in the incision line, separate interrupted incision line, separate interrupted absorbable sutures in figures-of-eight absorbable sutures in figures-of-eight should be placed in the bleeding area should be placed in the bleeding area to secure hemostasisto secure hemostasis

A perplexing circumstance occurs in closing a trans verse lower A perplexing circumstance occurs in closing a trans verse lower uterine segment incision when the junc tion of the contractile uterine segment incision when the junc tion of the contractile and noncontractile portion of the posterior wall presents the and noncontractile portion of the posterior wall presents the

appearance of the lower edge of the incisionappearance of the lower edge of the incision..

Suturing this to the upper cut edge would Suturing this to the upper cut edge would create a closure of the corpus, but the create a closure of the corpus, but the error is usually recognized when the lower error is usually recognized when the lower cut edge presents when peritoneal closure cut edge presents when peritoneal closure is attempted. The confusion can be is attempted. The confusion can be resolved by careful identifica tion of the resolved by careful identifica tion of the upper and lower edges of the uterine in upper and lower edges of the uterine in cisions at both angles.cisions at both angles.

When the uterus and visceral peritoneum have been When the uterus and visceral peritoneum have been reapproximated, the packs are removed from the reapproximated, the packs are removed from the

abdominal cavity and any residual blood or amniotic abdominal cavity and any residual blood or amniotic fluid removed by suction.fluid removed by suction.

If meconium soilage or exposure to If meconium soilage or exposure to infected amniotic fluid has occurred, the infected amniotic fluid has occurred, the pelvic cavity should be lavaged with pelvic cavity should be lavaged with normal saline solution. Clinical studies normal saline solution. Clinical studies have demonstrated in high-risk patients a have demonstrated in high-risk patients a reduction in postoperative infection rates reduction in postoperative infection rates if the uterine cavity is lavaged by saline if the uterine cavity is lavaged by saline solutionsolution

1)forceps 1)forceps operationsoperations2)Vacuum2)Vacuum extractor extractor

Operative delivery

Simpson forcepsSimpson forceps

2)Vacuum2)Vacuum extractor extractor

Laceration of birth canalLaceration of birth canal

Laceration of birth canalLaceration of birth canal